Minimally invasive right colectomy with transrectal natural orifice extraction: could this be the next step forward?

BACKGROUND: The transvaginal natural orifice specimen extraction (NOSE) approach for right-side colon surgery has been proven to exhibit favorable short-term outcomes. However, thus far, no study has reported the advantages of transrectal NOSE for right-side colon surgery. The aim of this study was to compare the technical feasibility, safety, and short-term outcomes of minimally invasive right hemicolectomy using the transrectal NOSE method and those of conventional mini-laparotomy specimen extraction. METHODS: A study was conducted on consecutive patients who had minimally invasive right hemicolectomy either for malignancy or benign disease at Chang Gung Memorial Hospital, Linkou, Taiwan, between January 2017 and December 2018. The patients were divided into two groups: conventional surgery with specimen extraction using mini-laparotomy and NOSE surgery. Surgical outcomes, including complications, postoperative short-term recovery, and pain intensity, were analyzed. RESULTS: We enrolled 297 patients (151 males, mean age 64.9 ± 12.8 years) who had minimally invasive right hemicolectomy. Of these 297 patients, 272 patients had conventional surgery with specimen extraction through mini-laparotomy and 25 patients had NOSE surgery (23 transrectal, 2 transvaginal). The diagnosis of colon disease did not differ significantly between the conventional and NOSE groups. Postoperative morbidity and mortality rates were comparable. The postoperative hospital stay was significantly (p = 0.004) shorter in the NOSE group (median 5 days, range 3-17 days) than in the conventional group (median 7 days, range 3-45 days). Postoperative pain was significantly (p = 0.026 on postoperative day 1 and p = 0.002 on postoperative day 2) greater in the conventional group than in the NOSE group. CONCLUSIONS: NOSE was associated with acceptable short-term surgical outcomes that were comparable to those of conventional surgery. NOSE results in less postoperative wound pain and a shorter hospital stay than conventional surgery. Larger studies are needed.

Synchronous colorectal carcinoma: predisposing factors and characteristics.

AIM: Whether some diseases are related to the occurrence of synchronous colorectal carcinoma (sCRC) is unknown. Investigating the risk factors and presentation of sCRC could aid in the treatment of patients with colorectal cancer (CRC). The prognosis of sCRC compared with that of solitary CRC remains unclear. METHODS: A total of 17 093 CRC patients were recruited between 1st January 1995 and 31th December 2016. The risk factors of sCRC development were assessed using univariate and multivariate logistic regression. The effect of sCRC on survival was analysed using the multivariate Cox regression model. RESULTS: The prevalence of sCRC was 5.6% in this study. The independent risk factors of sCRC development were advanced age (P < 0.001), male sex (P < 0.001), hereditary cancer (P < 0.001), hypertension (P < 0.001) and liver cirrhosis (P = 0.024). Compared with solitary CRC, a higher number of patients with sCRC presented with an abnormal carcinoembryonic antigen (CEA) level (P = 0.011), anaemia (P < 0.001) and hypoalbuminemia (P < 0.001). Multivariate analysis revealed that sCRC was a significant factor for poor survival in patients at TNM Stage I [hazard ratio (HR) = 1.86; P < 0.001], Stage II (HR = 1.65; P < 0.001) and Stage III (HR = 1.40; P < 0.001). CONCLUSIONS: In addition to hypertension and liver cirrhosis, other risk factors for sCRC were identified in this study. The prognosis of patients with sCRC was significantly worse than that of those with solitary CRC through TNM Stages I to III. Anaemia, abnormal CEA and hypoalbuminemia were more commonly seen in patients with sCRC.

Pre-operative serum albumin level substantially predicts post-operative morbidity and mortality among patients with colorectal cancer who undergo elective colectomy.

The quantitative relationship between serum albumin level and surgical outcomes has not been clearly established. This study included 3732 patients with colon cancer who underwent a potentially curative colectomy. Post-operative mortality and morbidity were analysed according to the patients' demographic data, pre-operative comorbidities, and tumour-related factors. Age, asthma, renal impairment, and albumin level were significantly associated with post-operative morbidity and mortality in the multivariate analyses. Logistic regression analysis revealed linear relationships of post-operative morbidity and mortality with albumin level. The morbidity and mortality rates decreased by 7.3% and 15.6%, respectively, for each 0.1 g/dL increase in albumin level. This finding remained significant in the hypoalbuminaemia subgroup but not in the normoalbuminaemia subgroup. That is, the morbidity and mortality rates significantly decreased by 8.7% and 17.7%, respectively (both P < 0.001), in the former group and decreased by 2.7% (P = 0.112) and 11.6% (P = 0.092), respectively, in the latter group. This study demonstrated that serum albumin level linearly predicted the post-operative morbidity and mortality among the colorectal cancer patients. Pre-operative serum albumin level may therefore be used as a continuous rather than a categorical marker of disease severity, especially among patients with hypoalbuminaemia.

Mucinous adenocarcinoma showing different clinicopathological and molecular characteristics in relation to different colorectal cancer subgroups.

BACKGROUND: Mucinous adenocarcinoma (MAC) is frequently reported to be associated with patients of young-age sporadic colorectal cancer (YSCC) and hereditary nonpolyposis colorectal cancer (HNPCC). This study is aimed to investigate whether the clinicopathological characteristics of MAC of HNPCC patients are distinct from those of YSCC patients. PATIENTS AND METHODS: Eighty-two HNPCC and 68 YSCC patients recorded in the colorectal cancer registry of Chang Gung Memorial Hospital at Linkou, Taiwan, between January 1, 1995 and December 31, 2001 were included in this study. Clinicopathological and molecular variables of MAC and non-MAC of HNPCC and YSCC patients were compared accordingly. RESULTS: Compared to non-MAC, MAC significantly showed higher frequencies of poor differentiation (32% vs. 8.2%, p = 0.001), advanced tumor stage (76% vs. 47%, p = 0.002), loss of mismatch repair protein (MMR) expression (74% vs. 44%, p = 0.023), and increased MUC2 expression (98% vs. 61%, p < 0.001). MAC of HNPCC patients showed predominant right-sided colon involvement, whereas MAC of YSCC patients displayed predominance in the left colon (79% vs. 22%, p = 0.001). Among the non-MAC counterparts, more differences were detectable including tumor stage, loss of MMR expression, and increased MUC1 expression. Furthermore, both MAC and non-MAC of YSCC patients showed higher frequencies of advanced tumor stage (81% vs. 62%, p = 0.072). In contrast, the incidence of loss of MMR expression in MAC and non-MAC of HNPCC patients is not significantly different (86% vs. 70%, p = 0.323). CONCLUSIONS: Significantly different tumor localization was observed between mucinous YSCC (left colon predominance) and mucinous HNPCC (right colon predominance).

Mutation analysis of the APC gene in Taiwanese FAP families: low incidence of APC germline mutation in a distinct subgroup of FAP families.

Familial adenomatous polyposis (FAP) is an autosomal-dominant disease caused by germline mutations in the adenomatous polyposis coli (APC) gene. The affected individuals develop colorectal polyposis and show various extra-colonic manifestations. In this study, we aimed to investigate the genetic and clinical characteristics of FAP in Taiwanese families and analyze the genotype-phenotype correlations. Blood samples were obtained from 66 FAP patients registered in the hereditary colorectal cancer database. Then, germline mutations in the APC genes of these 66 polyposis patients from 47 unrelated FAP families were analyzed. The germline-mutation-negative cases were analyzed by performing multiplex ligation-dependent probe amplification (MLPA) and single-strand conformation polymorphism (SSCP) analysis of the MUTYH gene. Among the analyzed families, 79% (37/47) of the families showed 28 APC mutations, including 19 frameshift mutations, 4 nonsense mutations, 3 genomic deletion mutations, 1 missense mutation, and 1 splice-site mutation. In addition, we identified 15 novel mutations in 32% (15/47) of the families. The cases in which APC mutations were not identified showed significantly lower incidence of profuse polyposis (P = 0.034) and gastroduodenal polyps (P = 0.027). Furthermore, FAP families in which some affected individuals had less than 100 polyps showed significant association with low incidence of APC germline mutations (P = 0.002). We have added the APC germline-mutation data for Taiwanese FAP patients and indicated the presence of an FAP subgroup comprising affected individuals with nonadenomatous polyps or less than 100 adenomatous polyps; this form of FAP is less frequently caused by germline mutations of the APC gene.

Clinicopathological analysis of colorectal cancer liver metastasis and intrahepatic cholangiocarcinoma: are they just apples and oranges?

BACKGROUNDS/AIMS: Intrahepatic cholangiocarcinoma and colorectal cancer liver metastasis are the most primary and secondary adenocarcinoma of the liver, respectively. A large-scale long-term comparative study of these two cohort patient is lacking. METHODS: A total of 166 colorectal cancer liver metastasis patients and 206 intrahepatic cholangiocarcinoma patients who had undergone curative liver resection were retrospectively analysed. Among 206 intrahepatic cholangiocarcinoma, there were 47 intraductal growth type-intrahepatic cholangiocarcinoma and 159 non-intraductal growth type-intrahepatic cholangiocarcinoma. The demographics, clinicopathological data, immunohistochemical study and survival were analysed. RESULTS: The intrahepatic cholangiocarcinoma patients were more female-predominated, associated with hepatolithiasis, symptomatic, jaundiced, and with larger tumour size compared with those of colorectal cancer liver metastasis. Prognostic factors of intrahepatic cholangiocarcinoma were pathologic staging, histologic pattern and section margin; whereas prognostic factors of colorectal cancer liver metastasis were rectal origin, differentiation, section margin and bilobar distribution. CK7 and CK20 differentiated majority of intrahepatic cholangiocarcinoma from colorectal cancer liver metastasis, while CDX2 and MUC5AC helped to differentiate inconclusive cases. The 1-, 3-, 5- and 10-year survival rates of colorectal cancer liver metastasis were 77%, 31%, 20% and 14%, compared to 53%, 21%, 13% and 7% of intrahepatic cholangiocarcinoma (p=.0001). Furthermore, the survival of colorectal cancer liver metastasis was comparable to staged II intrahepatic cholangiocarcinoma (p=.8866) and intraductal growth type-intrahepatic cholangiocarcinoma (p=.1915). CONCLUSIONS: Demographics, precipitating factor, clinical manifestations, and prognostic factors of colorectal cancer liver metastasis and intrahepatic cholangiocarcinoma differed remarkably. High incidence of CDX2 and MUC2 expression in colorectal cancer liver metastasis and intraductal growth type-intrahepatic cholangiocarcinoma might explain their similar cytoarchitecture and survival.

Mismatch repair protein expression in Amsterdam II criteria-positive patients in Taiwan.

BACKGROUND: Hereditary non-polyposis colorectal cancer (HNPCC) is characterized genetically by germline mutations in DNA mismatch repair (MMR) genes. Immunohistochemistry (IHC) has high sensitivity and specificity for identifying MMR-deficient tumours. This study investigated the clinical presentations and frequency of HNPCC in Taiwan by combined Amsterdam II criteria (AC-II) and IHC. METHODS: In 1995-2003, 7108 patients with primary colorectal cancer registered in Chang Gung Memorial Hospital's Colorectal Cancer Registry were screened using AC-II. Tumour specimens were analysed for MMR protein expression by IHC, and relevant clinicopathological details were documented. RESULTS: Some 83 patients fulfilled the AC-II. Clinicopathologically, 43 patients (52 per cent) had proximal tumours, ten (12 per cent) had poorly differentiated cancers, 17 (20 per cent) had mucinous adenocarcinoma and 51 (61 per cent) had stage I-II tumours. Seventeen patients developed second primary colonic and extracolonic cancers over a mean 7.2-year follow-up. Immunohistochemically, 58 patients were MMR protein deficient. They had a significantly earlier age of onset (P < 0.001), more proximal tumour location (P = 0.002), less advanced tumour stage (P = 0.008) and more second primary cancers (P = 0.017) compared with MMR-competent patients. CONCLUSION: These data show significant differences in clinical features between MMR protein-deficient and MMR competent subgroups.

Concentrations of nine alkenylbenzenes, coumarin, piperonal and pulegone in Indian bidi cigarette tobacco.

Indian-made bidi cigarettes sold in the United States are available in a variety of exotic (e.g. clove, mango) and candy-like (e.g. chocolate, raspberry) flavors. Because certain tobacco flavorings contain alkenylbenzenes and other toxic or carcinogenic chemicals, we measured the concentration of flavor-related compounds in bidi tobacco using a previously developed method. Twenty-three brands of bidis were sampled using automated headspace solid-phase microextraction and subsequently analyzed for 12 compounds by gas chromatography-mass spectrometry. Two alkenylbenzene compounds, trans-anethole and eugenol, were found in greater than 90% of the brands analyzed. Methyleugenol, pulegone and estragole were each detected in 30% or more of the brands, whereas safrole and elemicin were not detected in any of the brands. The flavor-related compounds with the highest tobacco concentrations were eugenol (12,000 microg/g tobacco) and trans-anethole (2200 microg/g tobacco). The highest eugenol and trans-anethole concentrations found in bidi tobacco were about 70,000 and 7500 times greater, respectively, than the highest levels previously found in US cigarette brands. Measurement of these compounds is crucial to evaluation of potential risks associated with inhaling highly concentrated flavor-related compounds from bidis or other tobacco products.

Nuclear beta-catenin expression is closely related to ulcerative growth of colorectal carcinoma.

Although most colorectal cancer develops based on the adenoma-adenocarcinoma sequence, morphologically, colorectal cancer is not a homogeneous disease entity. Generally, there are two distinct morphological types: polypoid and ulcerative colorectal tumours. Previous studies have demonstrated that K-ras codon 12 mutations are preferentially associated with polypoid growth of colorectal cancer; however, little is known about the molecular mechanism that determines ulcerative growth of colorectal cancer. beta-catenin complex plays a critical role both in tumorigenesis and morphogenesis. We examined the differential expression of beta-catenin and its related factors among different types of colorectal cancer in order to determine any relationship with gross tumour morphology. Immunohistochemical staining of beta-catenin, E-cadherin and MMP-7 was performed on 51 tumours, including 26 polypoid tumours and 25 ulcerative tumours. Protein truncation tests and single-strand conformational polymorphism for mutation of the adenomatous polyposis coli tumour suppressor gene, as well as single-strand conformational polymorphism for the mutation of beta-catenin exon 3 were also done. Nuclear expression of beta-catenin was observed in 18 out of 25 (72%) cases of ulcerative colorectal cancer and seven out of 26 (26.9%) cases of polypoid colorectal cancer. A significant relationship of nuclear beta-catenin expression with ulcerative colorectal cancer was found (P<0.001). However, this finding was independent of adenomatous polyposis coli tumour suppressor gene mutation and E-cadherin expression. Together with previous data, we propose that different combinations of genetic alterations may underlie different morphological types of colorectal cancer. These findings should be taken into consideration whenever developing a new genetic diagnosis or therapy for colorectal cancer.

Humoral response to p53 in human colorectal tumors: a prospective study of 1,209 patients.

p53 Antibodies (p53-Abs) have been detected in the serum of a proportion of colorectal cancer (CRC) patients. It is not yet known at which stage during colorectal tumor progression p53-Abs appear in the serum. The utility of these antibodies as markers for CRC prognosis remains to be clarified. Using a quantitative enzyme-linked immunosorbent assay, we analyzed serum samples from 998 CRC patients and from 211 patients with polyp. Levels of p53-Abs were defined as negative (<10 U/microL), low (10-76 U/microL) and high (>76 U/microL). Overall, 13.0% of CRC patients and less than 1% of polyp patients had increased serum p53-Ab levels. High p53-Ab levels were only seen in patients with invasive carcinomas. The parameters that were significantly and independently associated with a greater frequency of high p53-Ab levels were the left colon (odds ratio [OR] = 3.4; 95% CI = 1.1-10.5), the rectum (OR = 2.9; 95% CI, 1.0-8.8) and advanced lymph node metastasis (OR = 4.6; 95% CI, 2.2-9.6). In univariate analysis, patients with high p53-Ab levels had a shorter survival times than did those without (p = 0.007). However, the significant effect disappeared in a Cox regression model adjusting for sex, age, tumor location, carcinoembryonic antigen levels, gross findings, histologic grade, mucin production and TNM stage. Thus, autoantibodies against p53 occur with tumor progression in multistep colorectal carcinogenesis and increase with advanced node metastasis. Furthermore, the seemingly adverse effect of high p53-Ab levels on the survival of CRC patients may be explained by other prognostic factors.

Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients.

OBJECTIVE: To identify the risk factors for surgical site infection (SSI) in patients undergoing elective resection of the colon and rectum. SUMMARY BACKGROUND DATA: SSI causes a substantial number of deaths and complications. Determining risk factors for SSI may provide information on reducing complications and improving outcome. METHODS: The authors performed a prospective study of 2,809 consecutive patients undergoing elective colorectal resection via laparotomy between February 1995 and December 1998 at a single institution. The outcome of interest was SSI, which was classified as being incisional or organ/space with or without clinical leakage. A likelihood ratio forward regression model was used to assess the independent association of variables with SSIs. RESULTS: The overall SSI, incisional SSI, and organ/space SSI with and without clinical anastomotic leakage rates were 4.7%, 3%, 2%, and 0.8%, respectively. Risk factors for overall SSI were American Society of Anesthesiology (ASA) score 2 or 3 (odd ratio [OR] = 1.7), male gender (OR = 1.5), surgeons (OR = 1.3-3.3), types of operation (OR = 0.3-2.1), creation of ostomy (OR = 2.1), contaminated wound (OR = 2.9), use of drainage (OR = 1.6), and intra- or postoperative blood transfusion (1-3 units, OR = 5.3; >/=4 units, OR = 6.2). However, SSIs at specific sites differed from each other with respect to the risk factors. Among a variety of risk factors, only blood transfusion was consistently associated with a risk of SSI at any specific site. CONCLUSIONS: In addition to ASA score and surgical wound class, blood transfusion, creation of ostomy, types of operation, use of drainage, sex, and surgeons were important in predicting SSIs after elective colorectal resection.

Primary colorectal lymphoma.

PURPOSE: The purpose of this study was to review the clinical presentation and characteristics of primary colorectal lymphoma, analyze the prognostic factors, and assess the results of treatment with adjuvant chemotherapy. METHODS: We identified 37 cases at our institution between 1980 and 1996. They comprised 0.48 percent of all cases of colon malignancies (37/7,658) during this period. The following clinical information was obtained: age, gender, signs and symptoms, tumor site, tumor size, histology grade, pathology, and adjuvant chemotherapy. RESULTS: The most common presenting signs and symptoms were abdominal pain (62 percent), abdominal mass (54 percent), and weight loss (43 percent). The most frequent site of involvement was the cecum (45 percent). Histologically, 29 (78 percent) were classified as high-grade, and 8 (22 percent) as intermediate-grade-to-low-grade lymphoma. Nine (24.3 percent) of the cases were Stage EI, 23 (62.2 percent) were Stage EII, and 5 (13.5 percent) were Stage EIV. Twenty-one (57 percent) cases received adjuvant chemotherapy. The five-year survival rate was 33 percent for all patients and 39 percent for patients treated with combination chemotherapy. Overall median survival time was 24 months and 36 months for those with adjuvant chemotherapy. Only histology grade, among the factors examined, was a significant prognostic factor for survival. The mean survival time of the patients with Stage II disease who received chemotherapy was 117.4 months, and it was 47.9 months for the patients with Stage II disease who did not received chemotherapy. CONCLUSIONS: In our retrospective study high-grade lymphoma was the only significant adverse prognostic factor for survival. Receiving adjuvant chemotherapy significantly improved survival in patients with Stage II disease. Patients with diffuse large-cell type had better survival than patients with small noncleaved-cell type in Stage II high-grade lymphoma.

A simplified regimen of weekly high dose 5-fluorouracil and leucovorin as a 24-hour infusion in patients with advanced colorectal carcinoma.

BACKGROUND: Reports of in vitro experiments in colorectal carcinoma cells suggest that prolonged cellular exposure to 5-fluorouracil (5-FU) combined with relatively low concentrations of leucovorin (LV) provides optimal enhancement of 5-FU efficacy. In this study, a simplified regimen of weekly 24-hour infusion of high dose 5-FU combined with a relatively low dose of LV was used to treat patients with advanced colorectal carcinoma. METHODS: Thirty-six patients with advanced colorectal carcinoma received 5-FU, 2600 mg/m2, admixed with LV, 100 mg/m2, in a portable infusion pump administered intravenously over a 24-hour period. High dose 5-FU/LV was delivered once a week for 5 consecutive weeks followed by a 1-week recovery period. All patients were assessable for toxicity and response. RESULTS: Two complete responses and 15 partial responses were observed (response rate of 47.2%; 95% confidence interval, 30.1-64.4%). The median response duration was 9.6 months. The median survival and time to progression were 11.9 months and 7.1 months, respectively. The toxicity was mild and acceptable. The major dose-limiting factors were hand-foot syndrome and fatigue. CONCLUSIONS: This simplified regimen of weekly 24-hour continuous infusion of high dose 5-FU/LV is an effective regimen in the treatment of patients with advanced colorectal carcinoma. Further study of the pharmacokinetics of combination therapy with 5-FU and LV as used in this regimen and its correlation with response and toxicity is warranted.

Segmental colectomy in the management of colonic inertia.

Subtotal colectomy with ileorectostomy has been proposed for the management of colon inertia-type constipation. However, many patients experience frequent bowel movements, watery diarrhea, or both after such a treatment. The purpose of this study is to determine the proper colectomy with which to treat colon dysmotility constipation without the negative side effects of frequent bowel movements, watery diarrhea, or both. Forty idiopathic constipation patients were studied. All of the patients showed a prolonged right or left colon transit time and normal transit time of the sigmoid and rectum. They received different types of colectomies (left, right, and subtotal) according to the distribution or accumulation of markers in the colon. Within 3 months of surgery, all of the patients experienced a dramatic improvement of their symptoms without frequent bowel movements or watery diarrhea. No significant complications developed after surgery. All the patients were followed up for at least 2 years. Most of them (37 cases) still had satisfactory bowel movements and no other constipation symptoms. However, 3 of the 40 cases developed symptoms of constipation 1 1/2 to 2 years after surgery. They all received subtotal colectomy with ileorectal anastomosis subsequently. They reobtained satisfactory bowel movements and experienced a subsidence of other constipation symptoms 3 months later. These results suggest that directed segmental colectomy can improve colonic inertia constipation without the consequence of frequent bowel movements and diarrhea.

K-ras codon 12 mutation determines the polypoid growth of colorectral cancer.

Colorectal carcinogenesis is widely thought to follow the adenoma-adenocarcinoma sequence. However, there are two morphologically distinct subtypes of colorectal cancer (CRC), polypoid and ulcerative. We conducted a comparative study to clarify whether different combinations of some commonly involved genetic alterations (including mutations in K-ras, p53, DCC, APC, and Rb genes) may exist between polypoid- and ulcerative-type CRCs, the two morphologically distinct types of CRC. By using PCR-based RFLP, single-strand conformational polymorphism, and loss of heterozygosity analysis, we found that K-ras codon 12 mutation was preferentially involved in polypoid tumor (P < 0.0001). There were no other significant correlations with p53 point mutation or loss of heterozygosity in chromosomes 5q, 17p, and 18q and Rb gene, which have been suggested to be involved in the progression of CRC of both morphological types. Therefore, different combinations of molecular genetic alterations may be involved in morphologically distinct types of colorectal carcinogenesis, and the K-ras codon 12 mutations may play an important role in polypoid growth of CRC. These results shed light on the function of K-ras oncogenes involved in colorectal carcinogenesis and may be important in the future design of genetic screening programs, determination of prognosis, and treatment for patients with CRC.

Role of K-ras mutations in colorectal carcinoma.

In order to investigate whether two common types of colorectal cancer with different gross appearances share the same incidence of K-ras mutation, the occurrence of a point mutation in codon 12 or codon 13 of the K-ras oncogene was determined in 50 cases of colorectal carcinoma. The PCR technique was employed, followed by RFLP analysis and sequencing to identify specific point mutations. No correlation was found between the presence of a K-ras gene mutation and histological parameters. A strong association was found between K-ras mutations and the gross polypoid appearance of colorectal carcinoma (polypoid 73% versus ulcerative 8%). The results indicate a preferential association with the K-ras oncogene involved in polypoid type colorectal carcinoma.

Stapled colonic J-pouch-anal anastomosis without a diverting colostomy for rectal carcinoma.

PURPOSE: Colonic J-pouch reconstruction is designed to improve functional outcome of coloanal anastomosis. Most surgeons use a diverting colostomy to avoid severe pelvic sepsis caused by anastomotic breakdown. METHODS: We report the outcome of 30 consecutive patients with colonic J-pouch-anal anastomosis without a diverting colostomy performed between November 1992 and October 1993. All patients had carcinoma of the lower two-thirds of the rectum. Patients were seen every three months. Functional results were compared with those of 21 rectal cancer patients with straight coloanal anastomosis who underwent surgery in the same period and 20 normal patients. RESULTS: There were two anastomotic leakages and one postoperative death. After one year, patients with pouch anastomosis had significantly less frequency of defecation and rectal urgency compared with those with straight anastomosis (P < 0.01); 48 percent of patients with straight anastomosis had more than five bowel movements per day, whereas all patients with pouch anastomosis had five or less bowel movements per day. Manometric studies showed maximum tolerable volume was significantly higher in patients with pouch anastomosis (81 vs. 152 ml; P < 0.01). CONCLUSIONS: Stapled colonic J-pouch-anal anastomosis without a diverting colostomy is a reliable procedure that provides good, long-term functional results.

Biofeedback therapy for excessive stool frequency and incontinence following anterior resection or total colectomy.

PURPOSE: Excessive stool frequency and incontinence after anterior resection (AR) or total colectomy (TC) can be refractory to expectancy and antidiarrheal agents. We prospectively assessed efficacy of anorectal biofeedback therapy (BF) in this clinical situation. METHODS: Thirteen patients (10 men and 3 women; mean age, 62.1 (standard error of the mean (SEM), 4.6) years) had more than six bowel movements per day and/or episodes of incontinence, which did not abate after antidiarrheal agents were given for at least six (mean, 27.9 (SEM, 6.3)) months after surgery. All underwent four sessions of outpatient BF. Assessment was by continence questionnaire and anorectal physiology tests, which were administered before and after BF. RESULTS: In seven AR patients, daily stool frequency was decreased (8.7 (SEM, 2.1) before and 4.6 (SEM, 1.2) after, P < 0.05), and daily incontinence episodes were reduced (2.7 (SEM, 0.9) before and 0.4 (SEM, 0.2) after, P < 0.05) after BF. Six TC patients also had decreased daily stool frequency (6.2 (SEM, 2.1) before, 3.3 (SEM, 1.6) after; P < 0.05) and incontinence episodes (2.4 (SEM, 0.9) before, 0.5 (SEM, 1) after; P < 0.05) after BF. There were no significant changes in anorectal physiology parameters after BF. At a mean follow-up of 10.6 (SEM, 2.5) months after BF, there were no regressions or complications. CONCLUSIONS: BF is a safe and effective option for refractory excessive stool frequency and/or incontinence following AR or TC.

Resection of liver metastases from colorectal cancer: are there any truly significant clinical prognosticators?

PURPOSE: This study was designed to evaluate the prognostic significance of various prognostic factors affecting recurrence after resection of colorectal hepatic metastases. PATIENTS AND METHODS: Records of 54 patients who had hepatic resection between 1986 and 1993 for metastatic liver tumor from colorectal cancer were reviewed. Factors analyzed were those reported to be of prognostic significance in other studies, including gender, primary tumor site, Dukes stage, diagnostic interval, grade, preoperative carcinoembryonic antigen (CEA) level, number of metastases, size of metastases, distribution of metastases, type of resection, resection margin, and estimated blood loss. RESULTS: Average follow-up of surviving patients was 28 (range, 12-89) months. Average survival time from date of hepatic resection was 26 months, with an estimated actuarial survival rate of 25.5 percent at five years. Using the multivariate analysis of factors, gender and preoperative CEA level were shown to be significantly related to overall survival (P = 0.0455 and 0.054, respectively). Cancer of the right side colon had significant correlation with hepatic "recurrence" (P = 0.0071). CONCLUSIONS: Female patients and those with peroperative CEA values higher than 20 ng/ml have a better chance of survival following hepatic resection. Cancer of the right colon has a greater tendency for hepatic recurrence than that of the left colon.